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Transvaginal Ultrasonography and Hysteroscopy As Predictors of Endometrial Polyps in Postmenopause

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Transvaginal Ultrasonography and Hysteroscopy As Predictors of Endometrial Polyps in Postmenopause Research Article de Godoy Borges, Dias, Bonassi Machado, BorgesEndometrial & Spadoto polyp Dias in postmenopause 11 Research Article Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause Womens Health The study compared ultrasound and ambulatorial hysteroscopy as diagnostic Pítia Cárita de Godoy methods detecting endometrial polyps in postmenopause women. 281 women aged Borges*,1,3, Rogério Dias2, 1 41–82 years who underwent ambulatorial hysteroscopy were analyzed for presence Rogério Bonassi Machado , 1 of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness João Bosco Ramos Borges & Daniel Spadoto Dias3 ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and 1Department of Gynecology & Obstetrics, endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial Faculdade de Medicina de Jundiaí, polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, São Paulo, Brasil positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy 2Department of Gynecology, Obstetrics, of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, & Mastology, Faculdade de Medicina de 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, 3Post Graduation Program in Gynecology, which is not sufficient for accurate diagnosis. Obstetrics, & Mastology, Faculdade de Medicina de Botucatu da Universidade Keywords: endometrial polyp • endometrial thickening • hysteroscopy • menopause Estadual Paulista “Júlio de Mesquita • transvaginal ultrasonography Filho”- UNESP- Botucatu (SP), Brasil *Author for correspondence: Tel.: +55 11 4586 0660 A progressive increase in the incidence of When comparing hysteroscopy and trans- Fax: +55 11 4586 0660 endometrial polyps has been observed with vaginal ultrasonography with pathological [email protected] 10.2217/WHE.14.50 advancing age, being more common among findings, it is conclusive that they are both postmenopausal women [1,2]. Other risk fac- complimentary methods in the diagnosis of tors have also been identified such as late uterine intracavitary lesions. menopause, obesity, hypertension and the In conclusion, this study aims to evaluate use of hormones [3]. the accuracy of transvaginal ultrasonography Currently, the most appropriate inves- and ambulatorial hysteroscopy in the diagno- 1 tigative method available for evaluating sis of endometrial polyps in postmenopausal the uterine cavity in women with endo- women. metrial thickening, either asymptomatic or with vaginal bleeding, is the hysteros- Methods 2015 copy [4], considered by many authors as Into a retrospective study, data were the ‘gold standard’ for evaluation of the obtained through the consultation records endometrium. of 323 postmenopausal women undergo- Ambulatorial hysteroscopy is a procedure ing ultrasonography and hysteroscopy (Bet- to evaluate abnormalities of the endome- tocchi) with endometrial biopsy (directed trial cavity and has a high success rate. It is by hysteroscopy). The study included 281 advisable to always perform with a biopsy if postmenopausal women, characterized by the endometrial cavity measured by ultra- the presence of at least 1 year of amenor- sonography is greater than 5 mm, and also rhea and follicle-stimulating hormonal lev- in the case of any suspected malignancy, els of at least 30 mU/ml, aged 41–82 years even when there is a normal uterine cavity old, who had undergone ambulatorial hys- part of in hysteroscopy [5]. teroscopy for submitting uterine bleeding 10.2217/WHE.14.50 © 2015 Future Medicine Ltd Womens Health (2015) 11(1), 29–33 ISSN 1745-5057 29 Research Article de Godoy Borges, Dias, Bonassi Machado, Borges & Spadoto Dias and/or transvaginal ultrasound (endometrial echo Results greater than or equal to 5 mm), and for these reasons, The mean age of patients was 61.3 with a standard were referred to the outpatient hysteroscopy. Some of deviation of 7.6 years. Out of these patients, 27.6% these women are users of combined hormone therapy had diabetes mellitus Type 2, 70.5% had hyperten- or tamoxifen (treatment for breast cancer). The trans- sions and 5.7% were smokers. The average BMI was vaginal ultrasound was performed using the Toshiba 31.6 with a standard deviation of 5.8 kg/m2 (minimum model SAL 38B with a 5 MHz transducer and image- of 22.51 kg/m2 and maximum of 54.10 kg/m2). Out of type mechanical sector. The measurement of endome- these patients, a further 73% were multiparous (with trial thickness was taken in the longitudinal plane at three or more births). The average time after meno- its thickest point. It encompassed both layers of the pause was 10.7 with a standard deviation of 7.7 years endometrium and myometrium was taken from the (minimum of 1 year and a maximum of 37 years) inner edge of the anterior and posterior walls of the with 15.3% of the patients being users of combined uterus including the uterine cavity. In our country, hormone therapy. It was also observed that 6.8% were ultrasonography is routinely performed on women in treatment for breast cancer with tamoxifen. Table 1 approximately once a year. 42 women were excluded shows the reasons for performing a hysteroscopy and because they had already had records with missing the ultrasonographic findings that were obtained. or incomplete reports of transvaginal ultrasonogra- It was observed that via ultrasound, an endometrial phy and diagnostic hysteroscopy, and the absence polyp was detected in 22.8% of patients. The ultra- of anatomopathological results. Demographic data, sonographic diagnoses showed endometrial thicken- clinical characteristics, justifications for hysteroscopy ing (EE) in 59.8% of the patients, being an average and sonographic, hysteroscopic and anatomopatho- of 10.5 mm with a standard deviation of 5.5 mm logic finds, were reported as mean, standard deviation, (minimum of 1 mm and a maximum of 32 mm). absolute (n) and relative (%) frequency. The perfor- The hysteroscopy diagnosed endometrial polyps in mance of tests (ultrasonography and hysteroscopy) was 80.8% of patients. Other hysteroscopy diagnostics are assessed by sensitivity, specificity, positive predictive described in Table 2. value, negative predictive value and accuracy, as well Histopathological examinations confirmed the as confidence intervals of 95%. Comparison of tests presence of 79% of endometrial polyps and 21% of in terms of sensitivity and specificity was carried out nonendometrial polyps (other findings)Table 3. by the comparison of percentages by chi-square (c²) Ultrasonography showed high sensitivity and low test, and accuracy through the Z-test for proportions. specificity, with an accuracy of 75.4%, whereas hys- The significance level was 5%. The software used for teroscopy showed high sensitivity and high specific- analysis was SAS version 9.1. ity, with an accuracy of 91.8%. The results of the Table 1. Clinical indications of ambulatorial hysteroscopy and ultrasonographic findings for the group of women in the study. n % Indication Uterine bleeding 107 38.1 Altered ultrasonography 174 61.9 Ultrasonographic findings Normal 32 11.4 Submucosal myoma 5 1.8 Neoplasia 2 0.7 Hyperplasia 1 0.4 Thickening† 168 59.8 Endometrial polyp† 64 22.8 Endometrial polyp or submucosal fibroid† 7 2.5 Endometrial polyp or submucous myoma or 2 0.7 neoplasia† †Considered as endometrial polyps for the performance valuation of ultrasonography. 30 Womens Health (2015) 11(1) future science group Endometrial polyp in postmenopause Research Article Table 2. Hysteroscopic findings in the group of postmenopausal women. Hysteroscopy results n % Normal 32 11.4 Submucosal myoma 8 2.8 Uterine synechiae 4 1.4 Neoplasia 3 1.1 Endometrial hyperplasia 3 1.1 Cervical polyp 1 0.4 Endometrial thickening 1 0.4 Endometrial polyp 227 80.8 Endometrial polyps/submucosal fibroids 2 0.7 diagnostic tests are shown in Table 4. The difference It was observed that ambulatorial hysteroscopy was in sensitivity, specificity and accuracy of the val- sufficient in diagnosing 96.4% of endometrial polyps. ues observed in ultrasonography and hysteroscopy Other authors, in studies of a smaller sample using the was statistically significant (p < 0.0022, p < 0.0001, same technique, diagnosed 42.1% (n = 51) of endome- p < 0.0001, respectively). trial polyps [4]. Cacciatore et al. [10] while studying post- menopausal women with uterine bleeding (n = 45) diag- Discussion nosed 42.2% (n = 19). The difference can be explained Studies have demonstrated prevalence greater than by the higher number of women included in our study. 40% of polyps in women with postmenopausal bleed- There was evidence of endometrial polyps in 222 ing [6,7]. Ben Arie et al. found endometrial polyps in patients in the anatomopathologic exam. In turn, 54.9% of asymptomatic patients, and uterine bleed- the hysteroscopy method showed a suggestive image ing in 45.1% [8]. Accordingly, we observed the preva- of polyps in 229 patients. In this sense, the disagree- lence of endometrial polyps in 79% of postmenopausal ment between the hysteroscopic image and the anato- women. In the Orvieto study [9], 65% of women were mopathological result shows that even when hysteros- diagnosed with endometrial polyps after routine ultra- copy is done by an expert, there was the possibility of
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